Provider claim editing and settlement system

ABSTRACT

Methods and systems for interactively creating and submitting insurance claims and determining whether the submitted claims are in condition for payment by an insurer. A medical technician operating a client computer establishes communication with a remote server. The remote server transmits a claim form to the client computer for display to the medical technician. Using the claim form, the technician enters patient identification information, which is transmitted to the server to determine whether the patient is a beneficiary of an approved insurance plan. If the patient is a beneficiary, the technician can prepare an insurance claim using the claim form displayed by the client computer. The technician enters a diagnosis code and a treatment code representing the diagnosis and treatment of the patient. The diagnosis and treatment codes are transmitted to the remote server, which processes the codes to determine whether the claim corresponds to health care services that are approved for payment. If the insurance claim is not in condition for payment, the medical technician is notified. The medical technician can then amend the insurance claim as necessary and resubmit the claim.

BACKGROUND OF THE INVENTION

1. The Field of the Invention

The present invention relates to systems for creating and approvinghealth insurance claims. More particularly, the present inventionrelates to interactively creating insurance claims on a client computerthat communicates with a remote server computer, whereby a health careprovider can be almost immediately informed whether the createdinsurance claim is in condition to be paid.

2. Relevant Technology

The cost of health care continues to increase as the health careindustry becomes more complex, specialized, and sophisticated. Theproportion of the gross domestic product that is accounted for by healthcare is expected to gradually increase over the coming years as thepopulation ages and new medical procedures become available. Over theyears, the delivery of health care services has shifted from individualphysicians to large managed health maintenance organizations. This shiftreflects the growing number of medical, dental, and pharmaceuticalspecialists in a complex variety of health care options and programs.This complexity and specialization has created large administrativesystems that coordinate the delivery of health care between health careproviders, administrators, patients, payors, and insurers. The cost ofsupporting these administrative systems has increased during recentyears, thereby contributing to today's costly health care system.

A significant portion of administrative costs is represented by thesystems for creating, reviewing and adjudicating health care providerpayment requests. Such payment requests typically include bills forprocedures performed and supplies given to patients. Careful review ofpayment requests minimizes fraud and unintentional errors and providesconsistency of payment for the same treatment. However, systems forreviewing and adjudicating payment requests also represent transactioncosts which directly reduce the efficiency of the health care system.Reducing the magnitude of transaction costs involved in reviewing andadjudicating payment requests would have the effect of reducing the rateof increase of health care costs. Moreover, streamlining payment requestreview and adjudication would also desirably increase the portion of thehealth care dollar that is spent on treatment rather thanadministration.

Several factors contribute to the traditionally high cost of health careadministration, including the review and adjudication of paymentrequests. First, the volume of payment requests is very high. Largehealth management organizations may review tens of thousands of paymentrequests each day and tens of millions of requests yearly. In addition,the contractual obligations between parties are complex and may changefrequently. Often, there are many different contractual arrangementsbetween different patients, insurers, and health care providers. Theamount of authorized payment may vary by the service or procedure, bythe particular contractual arrangement with each health care provider,by the contractual arrangements between the insurer and the patientregarding the allocation of payment for treatment, and by what isconsidered consistent with current medical practice.

During recent years, the process of creating, reviewing, andadjudicating payment requests from health care providers has becomeincreasingly automated. For example, there exist claims processingsystems whereby technicians at health care providers' officeselectronically create and submit medical insurance claims to a centralprocessing system. The technicians include information identifying thephysician, patient, medical service, insurer, and other data with themedical insurance claim. The central processing system verifies that thephysician, patient, and insurer are participants in the claimsprocessing systems. If so, the central processing system converts themedical insurance claim into the appropriate format of the specifiedinsurer, and the claim is then forwarded to the insurer. Uponadjudication and approval of the insurance claims, the insurer initiatesa check to the provider. In effect, such systems bypass the use of themail for delivery of insurance claims.

In partially automated systems, such as that described in the foregoingexample, the technician can submit a claim via electronic mail on theInternet or by other electronic means. To do so, the technicianestablishes communication with an Internet service provider or anotherwide area network. While communication is maintained, the techniciansends the insurance claim to a recipient and then either discontinuescommunication or performs other activities while communication isestablished. Using such conventional systems, personnel at the healthcare provider's office are unable to determine whether the submittedclaim is in condition for payment and do not receive any indication,while communication is maintained, whether the claim will be paid.

Thus, while systems that permit electronic submission of insuranceclaims marginally decrease the time needed to receive payment byeliminating one or more days otherwise required to deliver claims bymail, they remain subject to many of the problems associated with otherclaims submission systems. For example, it has been found that a largenumber of insurance claims are submitted with information that isincomplete, incorrect, or that describes diagnoses and treatments thatare not eligible for payment. The claims can be rejected for any of alarge number of informalities, including clerical errors, patientineligibility, indicia of fraud, etc. The health care provider is notmade aware of the deficiencies of the submitted claims until a laterdate—potentially weeks afterwards—when the disposition of the insuranceclaim is communicated to the health care provider. As a result, manyclaims are subject to multiple submission and adjudication cycles, asthey are successively created, rejected, and amended. Each cycle maytake several weeks or more, and the resulting duplication of effortdecreases the efficiency of the health care system. Studies have shownthat some insurance claim submission systems reject up to 70% of claimson their first submission for including inaccurate or incorrectinformation or for other reasons. Many of the claims are eventuallypaid, but only after they have been revised in response to an initialrejection.

In order to attempt to minimize the number of claims that are rejected,physicians or their staff have had to spend inordinate amounts of timeinvestigating which treatments will be covered by various insurers andinsurance plans. The time spent in such activities represents furtherefficiency losses in the health care system.

Depending on a patient's insurance plan and the diagnosis and treatmentrendered, the patient may be required to make a co-payment representing,for example, a certain percentage of the medical bill or a fixed dollaramount. Because of the large number of insurers and insurance plans, theamount of the co-payment can vary from patient to patient and from visitto visit. Moreover, when a patient is not covered for certain treatment,the patient may be liable for the entire amount of the health careservices. It is sometimes difficult for technicians at the offices ofthe health care provider to determine that amount of any co-payment orany other amount due from the patient while the patient remains at theoffices after a medical visit. Once the patient leaves the office, theexpense of collecting amounts owed by patients increases and thelikelihood of being paid decreases. Conventional insurance claimsubmission systems have not been capable of efficiently and immediatelyinforming technicians at the offices of a health care provider ofamounts owed by patients, particularly when the amount is not a fixeddollar amount.

In view of the foregoing, there is a need in the art for more fullyautomated claims processing systems. For example, it would be anadvancement in the art to reduce the uncertainty as to whether a claimto be submitted is likely to be paid or rejected. Furthermore, it wouldbe advantageous to provide a claims processing system that would moreeasily allow health care providers to know what patient and treatmentinformation must accompany insurance claims. There also exists a needfor systems that allow health care providers to easily learn of thestatus of submitted insurance claims.

SUMMARY AND OBJECTS OF THE INVENTION

The present invention relates to methods and systems for interactivelycreating insurance claims. According to the invention, a medicaltechnician can prepare an insurance claim electronically, submit theclaim via the Internet or another wide area network, and receive almostimmediately an indication whether the submitted claim is in condition tobe paid. If the medical technician is informed that the claim is not incondition to be paid, the claim can be amended by correcting errors orotherwise placing the claim in condition to be paid. By using theinvention, health care providers can essentially eliminate thepossibility of having claims rejected after a lengthy adjudicationprocess. The invention can significantly reduce the time, effort, andexpense that have been associated with the submission of claims that arenot in condition to be paid.

According to the invention, communication is established between aclient computer operated by a medical technician and a remote servercomputer. The communication can be established using the Internet, adirect-dial telephone line, or any other suitable wide area networkinfrastructure. The client computer displays a computer-displayableclaim form to the medical technician. The claim form can be sent to theclient computer by the remote server or can instead be retrieved from alocal memory device. The claim form includes fields that permit themedical technician to enter patient identification information thatidentifies the patient. The patient identification information istransmitted from the client computer to the remote server. The remoteserver then determines whether the patient is a beneficiary of a healthinsurance plan and informs the client computer of the patienteligibility status.

Informing the medical technician almost immediately of the patient'sinsurance status allows the health care provider to select theappropriate treatment for the patient. The patient's eligibility statustransmitted from the remote server can include any desired amount ofdetail. For example, the eligibility status can describe the types ofdiagnoses and treatments for which payment will be made on behalf of thepatient, and the co-payment required by the patient.

If the patient is a beneficiary of an approved insurance plan, themedical technician can proceed with preparation of a full insuranceclaim. The claim form displayed by the client computer includes fieldsthat permit the medical technician to enter one or more diagnosis codesdescribing the diagnosis of the patient and one or more treatment codesdescribing the treatment administered to the patient. The claim form canalso include fields representing the identity of the health careprovider and any other desired information.

The diagnosis and treatment codes are transmitted from the clientcomputer to the remote server. The remote server or a processorassociated therewith then processes the transmitted information todetermine whether the insurance claim is in condition to be paid. Forexample, the remote server can verify that all required information isincluded. The remote server can also determine whether the diagnosiscode and the treatment code correspond to currently accepted medicalpractice and to health care services that are covered by the particularinsurance plan of the patient. The remote server can also perform anydesired checks on the information in the insurance claim to determinewhether the claim has indicia of fraud, unusually expensive treatment,or any other feature that indicates that the validity or accuracy of theclaim should be further investigated.

If the insurance claim is not in condition to be paid, the remote servertransmits information to the client computer to inform the medicaltechnician. The information transmitted to the client computer caninclude an indication of the reason for rejection of the claim and,optionally, suggestions on how to remedy the problem. For instance, ifthe insurance claim does not include complete information, the medicaltechnician can be prompted to complete the claim form. The deficiency ofthe claim can be substantive, as well, in that the treatment code couldrepresent a treatment that is not considered to be compatible with thediagnosis. In this case, the health care provider can change thetreatment, otherwise amend the claim form, or inform the patient thatthe insurance plan will not cover the treatment. When a claim form hasbeen amended, the new information can be transmitted to the remoteserver to repeat the process of determining whether the claim is incondition to be paid.

When the remote server determines that the claim is in condition to bepaid, the remote server transmits information to the client computer tonotify the medical technician. The information transmitted to the clientcomputer can include data that represents an amount that is to be paidby the insurer on behalf of the patient. The medical technician can alsobe informed of any co-payment to be collected from the patient. Becausethe process of determining whether the claim is in condition for paymentcan occur almost instantaneously—typically in a matter of seconds orminutes—any co-payment can be collected from the patient while thepatient remains in the offices of the health care provider before orafter treatment.

In view of the foregoing, the invention provides systems and methods forproviding almost immediate feedback to the medical technician specifyingwhether a submitted claim is in condition to be paid. While the speed ofresponse can vary, depending on the data transmission rates between theclient computer and the remote server, the processing capabilities ofthe remote server, and the complexity of the verification process to beconducted by the remote server, the invention can provide almostimmediate response to submitted claims. The response time can be shortenough that the medical technician can create a claim, submit the claim,and be notified whether the claim is in condition for allowance withoutdiscontinuing communication between the client computer and the remoteserver, while continuing to view the claim form displayed by the clientcomputer, or without proceeding to another patient's claim beforereceiving the response. In any event, the response time is significantlyfaster than that of conventional systems, which do not permit theinteractive creation and modification of insurance claims.

The invention can significantly reduce the inefficiencies that areotherwise experienced in the health care system as claims are submitted,subjected to an adjudication process, and often rejected days, weeks, orlonger, after the claim was created. The claim creation and verificationsystems of the invention also allow health care providers to easilylearn of the types of treatments that are approved for payment forspecific diagnoses according to the patient's insurance plan. Inaddition, the invention increases the efficiency of collectingco-payments from patients and increases the likelihood that suchco-payments will be made.

Additional objects and advantages of the invention will be set forth inthe description which follows, and in part will be obvious from thedescription, or may be learned by the practice of the invention. Theobjects and advantages of the invention may be realized and obtained bymeans of the instruments and combinations particularly pointed out inthe appended claims. These and other objects and features of the presentinvention will become more fully apparent from the following descriptionand appended claims, or may be learned by the practice of the inventionas set forth hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

In order that the manner in which the above-recited and other advantagesand objects of the invention are obtained, a more particular descriptionof the invention briefly described above will be rendered by referenceto specific embodiments thereof which are illustrated in the appendeddrawings. Understanding that these drawings depict only typicalembodiments of the invention and are not therefore to be consideredlimiting of its scope, the invention will be described and explainedwith additional specificity and detail through the use of theaccompanying drawings in which:

FIG. 1 is schematic diagram illustrating an interactive system accordingto the invention, including a client system at the offices of a healthcare provider and a remote server system, whereby a medical techniciancan interactively prepare an insurance claim that is in condition to bepaid.

FIG. 2 illustrates an insurance claim form that enables a medicaltechnician to determine whether and to what extent a patient is abeneficiary of an approved insurance plan.

FIG. 3 illustrates an insurance claim form that enables a medicaltechnician to submit an insurance claim including one or more diagnosiscodes and one or more treatment codes.

FIG. 4a is a flow diagram illustrating one embodiment of the methods ofthe invention for determining whether and to what extent a patient is abeneficiary of an approved insurance plan.

FIG. 4b is a flow diagram depicting one embodiment of the methods forinteractively preparing an insurance claim that is in condition to bepaid.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention relates to methods and systems for interactivelypreparing and submitting insurance claims and verifying that the claimsare in condition to be paid. A medical technician at the offices of ahealth care provider operates a client computer that communicates with aremote server. According to one embodiment of the invention, the medicaltechnician views a computer-displayable claim form displayed by theclient computer and enters a diagnosis code and a treatment code thatdescribe a medical diagnosis and associated treatment for a patient. Thediagnosis code and the treatment code are transmitted to the remoteserver. The remote server performs an operation in response to thediagnosis code and the treatment code to determine if these codescorrespond to health care services that are approved for payment.

If the remote server determines that the submitted claim will not bepaid by an insurer, the remote server transmits information to theclient computer to inform the medical technician of this result. Inresponse, the medical technician can amend the treatment code or anyother desired information on the insurance claim to place the claim incondition to be paid. After amending the claim, the claim is againsubmitted to the remote server, where it is again analyzed to determinewhether it represents health care services that are approved forpayment.

According to one embodiment, when the remote server determines that thesubmitted claim is in condition to be paid, the remote server transmitsinformation to the client computer indicating the amount that is to bepaid by the insurer on behalf of the patient. The system can also informthe medical technician of any co-payment to be collected from thepatient.

Embodiments of the invention include or are incorporated incomputer-readable media having computer-executable instructions or datastructures stored thereon. Examples of computer-readable media includeRAM, ROM, EEPROM, CD-ROM or other optical disk storage, magnetic diskstorage or other magnetic storage devices, or any other medium capableof storing instructions or data structures and capable of being accessedby a general purpose or special purpose computer. Computer-readablemedia also encompasses combinations of the foregoing structures.Computer-executable instructions comprise, for example, instructions anddata that cause a general purpose computer, special purpose computer, orspecial purpose processing device to execute a certain function or groupof functions. The computer-executable instructions and associated datastructures represent an example of program code means for executing thesteps of the invention disclosed herein.

The invention further extends to computer systems for interactivelycreating and submitting insurance claims and determining whether theclaims are in condition to be paid. Those skilled in the art willunderstand that the invention may be practiced in computing environmentswith many types of computer system configurations, including personalcomputers, multi-processor systems, network PCs, minicomputers,mainframe computers, and the like. The invention will be describedherein in reference to a distributed computing environment, such as theInternet, where tasks are performed by remote processing devices thatare linked through a communications network. In the distributedcomputing environment, computer-executable instructions and programmodules for performing the features of the invention may be located inboth local and remote memory storage devices.

FIG. 1 illustrates one embodiment of the systems for interactivelycreating and submitting insurance claims according to the invention.Client system 10 may be located at the offices of a health care providerin order to allow a medical technician to create and submit insuranceclaims. As used herein, the term “health care provider” is to be broadlyconstrued to include any physician, dentist, medical practitioner, orany other person whose services can be compensated by a health insurer,a health maintenance organization, or the like. As used herein, the term“medical technician” represents any person who engages in the activityof preparing or submitting insurance claims on behalf of a health careprovider. Since medical technicians are typically employees of healthcare providers, representatives of health care providers, or may be thehealth care providers themselves, any of the claims that recite steps,operations, or procedures conducted by “health care providers” are to beconstrued to extend to the same steps, operations, or proceduresconducted by “medical technicians”, as well.

The term “insurance plan” extends to any contractual or other legalarrangement whereby medical and other related expenses are paid onbehalf of a beneficiary. Examples of insurance plans include healthmaintenance organizations, fee-for-service health care plans,employer-sponsored insurance plans, etc.

Client system 10 can be a general purpose computer, such as a PC, or aspecial purpose computer adapted to perform the functions and operationsdisclosed herein. Client system 10 may include a display device such asa monitor for displaying claim form 12, as will be disclosed in greaterdetail below, and one or more input devices such as a keyboard, a mouse,etc. for enabling a medical technician to enter the required informationto client system 10.

The embodiment illustrated in FIG. 1 also includes a server system 14located typically at a remote location with respect to client system 10.Server system 14 can include a general purpose computer or a specialpurpose computer adapted to execute the functions and operations of theinvention. For example, in FIG. 1, server system 14 includes a processor16, which represents a general purpose computing device for receivinginformation associated with insurance claims and for determining whetherthe received information corresponds to health care services that areapproved for payment. The operation of server system 14 and processor 16will be discussed in greater detail below.

In one embodiment, processor 16 is capable of accessing informationstored in a patient eligibility database 18 and an accepted medicalpractice database 20. Database 18 can include compilation of data thatenables server system 14 to determine whether a particular patientidentified at client system 10 is a beneficiary of an approved insuranceplan. Likewise, database 20 can be any compilation of data that enablesservice system 14 to determine whether the health care servicesassociated with a submitted claim are approved for payment under theparticular insurance plan of the patient.

While the illustrated components of server system 14 of FIG. 1 can belocated at a single remote site with respect to client system 10, otherembodiments of the invention employ a processor 16 and databases 18 and20 that may be located at different sites with respect to each other.The terms “server system” and “remote server” extend to the latter case,wherein the various components 16, 18, and 20 are located in adistributed environment unless specifically indicated otherwise.

In the embodiment of FIG. 1, client system 10 and server system 14communicate by means of Internet infrastructure 22. While the inventionis described herein in the context of the Internet, those skilled in theart will appreciate that other communications systems can be used, suchas direct dial communication over public or private telephone lines, adedicated wide area network, or the like.

Referring to FIG. 1, when a medical technician desires to prepare aninsurance claim for health care services provided to the patient, themedical technician operates client system 10 and establishescommunication with server system 14 or verifies that communication hasbeen established. For instance, the medical technician may use clientsystem 10 to dial into a modem pool associated with an Internet serviceprovider in Internet infrastructure 22. After communication with theInternet service provider has been achieved, client system 10 may beused to transmit a Uniform Resource Locator (URL) to the Internetinfrastructure 22 that requests access to resources provided by serversystem 14. Alternatively, any other suitable technique can be used toestablish communication between client system 10 and server system 14.

In many cases, client system 10 will maintain communication with serversystem 14 for an extended period of time during which claims formultiple patients are processed. For instance, client system 10 can be adedicated terminal that maintains communication with server system 14 inorder for numerous insurance claims to be created and processed.

Once communication has been established, the medical technician can useclient system 10 to request claim form 12 to be displayed on a monitorassociated with client system 10. Claim form 12, in one embodiment, is aHyper Text Markup Language (HTML) document retrieved from server system14 and displayed to the medical technician. Alternatively, claim form 12can have any other suitable format or can be stored at a local cache orany other local data storage system, thereby eliminating the need torepeatedly retrieve claim form 12 from a remote location as multipleinsurance claims are created.

FIG. 2 illustrates one example of a claim form 12A that enables amedical technician to verify that a patient is a beneficiary of aninsurance plan and to learn of the details of the insurance plan. Inthis embodiment, claim form 12A includes a field 26 to which a patientidentifier can be entered. Patient identification information, such aspatient identifier 28 of FIG. 1, is entered by the medical technicianclaim form 12A of FIG. 2. Depending on the manner in which the inventionis implemented, the medical technician may be required to enter otherinformation, such as other information 30 of FIG. 1, that identifies,for example, the insurance plan of the patient, the health careprovider, or the like. Turning to FIG. 2, claim form 12A in this exampleincludes a field 32 for identifying the insurance plan of the patient, afield 34 for receiving information identifying the health care providerand a field 36 for entering additional information identifying thepatient. As shown in FIG. 2, field 36 can be adapted to receive apatient's date of birth. Alternatively, any other information that canuniquely identify a particular patient from among a pool of patients canbe used in combination with fields 26 and 36. By way of example and notlimitation, the patient identification information entered to fields 26or 36 can include patient's social security number, or a number uniquelyassociated with the patient by an insurance plan or a health maintenanceorganization.

Referring now to FIG. 1, after the medical technician has enteredpatient identifier 28 and, optionally, other information 30, the medicaltechnician uses client system 10 to transmit the information to serversystem 14. In one embodiment, processor 16 compares patient identifier28 against data stored in patient eligibility database 18 to determineif the patient is a beneficiary of an insurance plan and, if so, thedetails of the benefit thereof If the patient is found not to be abeneficiary of an approved insurance plan, information is transmittedfrom server system 14 to client system 10 to inform the medicaltechnician of this result. Thus, when the patient is not a beneficiary,a medical technician and the health care provider can promptly learn ofthis status and take steps to advise the patient or provide appropriatemedical treatment.

If it is determined that the patient is a beneficiary, information islikewise transmitted from server system 14 to client system 10 informingthe medical technician of the patient's status. The information can alsoprovide details of the coverage provided to the patient that can allowthe health care provider to select the appropriate course of action forthe patient. The details can include the types of diagnoses andtreatments that are approved for payment.

When the health care provider makes a diagnosis and performs orprescribes treatment to the patient, the medical technician can completethe claim form by entering at least one diagnosis code 38 and onetreatment code 40. Referring now to FIG. 3, claim form 12B includesfields adapted to accept the diagnosis code and the treatment code.Claim form 12B of FIG. 3 and claims form 12A may be separate formsdisplayed to the medical technician using client system 10 or can beseparate portions of the single claim form. Claim form 12B, in theexample of FIG. 3, includes header information 42 that has beenautomatically prepared by the server system before claim form 12B wastransmitted to the client system. Providing a claim form 12B that isautomatically partially completed contributes to the efficiency of theclaims creation and submission processes of the invention. While claimform 12B represents a claim form that can be advantageously used by manyhealth care providers, the specific fields included in the form and theinformation displayed on the form may vary from one implementation toanother, depending on the type of health care provider, insurance plan,and other factors.

Claim form 12B includes a plurality of fields 44 designed to receive anddisplay diagnosis codes representing the health care provider'sdiagnosis of the patient or the nature of the patient's illness orinjury. Thus, as used herein, “diagnosis code” refers to any informationthat specifies or indicates a patient's condition as diagnosed by ahealth care provider. Any predefined set of diagnosis codes can be usedwith the invention.

Claim form 12B also includes one or more fields 46 designed to receiveand display treatment codes associated with the diagnosis code of field44. As used herein, “treatment codes” can represent any type of healthcare services such as clinical therapy, pharmacological therapy,therapeutic supplies or devices, or other goods or services that can bepaid for by health insurance plans or health maintenance organizations.The treatment codes can be selected from any desired set of predefinedtreatment codes that define various treatments that can be administeredto patients. In one embodiment, the diagnosis codes and the treatmentcodes can be selected from the codes and code modifiers of a volumeentitled Physician's Current Procedural Terminology (CPT), which ismaintained and updated annually by the American Medical Association.

As shown in FIG. 3, claims form 12B can include other fields, such asfields 48, that are to be completed by the medical technician before theinsurance claim is submitted. In this example, fields 48 are adapted toreceive and display information identifying the patient, a referringphysician, and the health care provider who is to receive payment forthe health care services provided to the patient.

When fields 44, 46, and 48 are filled out by the medical technician, themedical technician submits the information included in these fields toserver system 14 from client system 10. Referring again to FIG. 1,server system 14 receives this information and performs certainoperations in response thereto to determine whether the claim formcorresponds to health care services that are approved for payment by thepatient's insurance plan. For instance, processor 16 can compare thediagnosis code 38 and treatment code 40 with a compilation of currentlyaccepted medical procedures stored in database 20. In one embodiment,MDR may be used to determine whether the diagnosis codes and treatmentcodes correspond to health care services that are approved for payment.Upon learning of the invention disclosed herein, those skilled in theart will understand how MDR can be used to determine whether thesubmitted claim form represents health care services that are approvedfor payment.

Server system 10 also determines whether the information provided inclaim form 12B is sufficiently complete to place insurance claim incondition to be paid. For example, if the medical technicianinadvertently fails to include information that identifies the referringphysician, server system can detect this error and later notify clientsystem 10 of the deficiency.

The techniques for processing submitted insurance claims at serversystem 14 can be as complex as desired. In one embodiment, server system14 analyzes the information submitted using claim form 12B to determinewhether there are indicia of fraud or mistake, whether unusuallyexpensive health care services are listed in the claim, or whethermanual adjudication of the insurance claim is otherwise advisable. Ifthe claim exhibits any of the foregoing features, the claim may beforwarded to a human adjudicator for manual adjudication or may bereturned to the health care provider to allow revision of the claim.

One technique that is sometimes used by health care providers to collectmore money from insurance plans than is otherwise warranted is thepractice of unbundling medical procedures. “Unbundling” consists ofperforming, for example, multiple medical procedures on a patientthrough a single surgical incision while submitting an insurance claimfor the multiple medical procedures as if they had been performedseparately. Typically, when only one incision is required to performmultiple medical procedures, the payment to the operating physician isless than the payment would be if each of the multiple medicalprocedures had been conducted through separate incisions. Otherfraudulent unbundling techniques for submitting claims on multiplemedical procedures are sometimes used as well. Thus, server system 14can analyze the diagnosis codes and the treatment codes for indicia ofunbundling practices. Furthermore, server system 14 may conduct anyother checks on the submitted claim.

If server system 14 determines that insurance claims submitted using theclaim forms of the invention are not in the condition to be paid for anyreason, server system can transmit information to client system 10informing the medical technician of this result. In addition, theinformation transmitted to the client system can indicate the basis forrejecting the insurance claim. Thus the medical technician can beinformed that the claim form was not completely filled out, thetreatment code is inconsistent with the diagnosis code, or any of anumber of other possible reasons for rejecting the insurance claim. Inresponse, the medical technician can amend the insurance claim byentering the correct information to the fields of claim form 12B of FIG.3, if necessary. In other cases, the health care provider can beinformed that the recommended treatment defined by treatment code 40 ofFIG. 1 is not approved for payment by the patient's insurance plan. Thehealth care provider can then advise the patient and decide to proceedwith the treatment or to prescribe an alternative treatment that isapproved for payment.

If the medical technician wishes to amend the insurance claim, the newinformation is transmitted from client system 10 to server system 14 forprocessing. For example, the health care provider may decide that analternative treatment is appropriate for the patient, in which case themedical technician would enter a new treatment code to client system 10.Server system 14 then repeats the previously described process ofdetermining whether the amended insurance claim is in condition forpayment. The above-described process can be repeated as many times asdesired or necessary to create and submit an insurance claim thatdescribes health care services that are approved for payment by thepatient's insurance plan.

When server system 14 informs client system 10 that a submitted claim isin a condition for payment, the server system can transmit informationthat specifies the amount that will be paid by the insurer on behalf ofthe patient. For example, claim form 12B of FIG. 3 includes a field 50that displays a dollar amount when the server system has determined thatthe claim is in condition for payment. In the example of FIG. 3, fields52 permit the medical technician to enter an amount that is requestedfor the treatments defined by the treatment codes in fields 46.

To illustrate, the medical technician might enter in field 46 atreatment code that represents a physical exam performed by a physician.The medical technician could then enter in field 52 a dollar amount,such as $100, that is customarily charged by the physician for aphysical exam. Field 54 sums all dollar amounts entered in fields 52. Inthis example, if the physical exam was the only treatment rendered tothe patient, field 54 would also display a dollar amount of $100. If theserver system, when processing the submitted claim, determines that thepatient's insurer pays only $90 for a physical exam, field 50 displaysthe dollar amount of $90 when the insurance claims has been processedand returned to the client system. A balance due field 56 displays thedifference between the total charge field 54 and the amount paid field50. The dollar amount displayed in field 56 represents the amount thatis to be collected from the patient. As used herein, the term“co-payment” is defined to extend to the dollar amount displayed infield 56, representing the amount that is to be collected from thepatient beyond the payment that is approved by the insurer.

Using the invention, medical technicians and health care providers canbe informed of the status of submitted insurance claims in a relativelyshort amount of time that is significantly less than conventionalsystems, which may require days, weeks, or more. Indeed, for practicalpurposes, a response to the submitted insurance claim is received almostimmediately by the medical technician. It can be understood that thelimiting factors with respect to the speed of response include the datatransmission rate supported by Internet infrastructure 22 of FIG. 1 andthe other communication links between the various components of thesystem, the processing capabilities of processor 16 and other componentsof server system 14, and the complexity of the submitted claim and thenature of the claim processing techniques performed by server system 14.

In many cases, the response time is short enough that a medicaltechnician can conveniently continue viewing the claim form associatedwith a particular patient at client system 10 of FIG. 1 while serversystem 14 performs the operations that determine whether the submittedclaim is in condition to be paid. Thus, a medical technician canconsecutively create and submit a series of claims and receiveverification that the claims are in condition for payment. In otherwords, a medical technician can easily create, submit, and, ifnecessary, revise and resubmit, a single claim before proceeding to thenext claim in a series of claims, since the response time can be veryshort. This is in sharp contrast to prior art systems in which theresponse time of days, weeks, or longer make it entirely impractical formedical technicians to complete the entire claim creation andadjudication process for one claim before proceeding to the next claim.

The systems and methods disclosed herein can be practiced in combinationwith the systems disclosed in co-pending U.S. patent application Ser.No. 09/118,668, entitled “Internet Claims Processing System”, filed Jul.17, 1998, which is incorporated by reference for purposes of disclosure.For example, the payment systems and payment tracking systems of theforegoing patent application can be employed with the insurance claimcreation and submission techniques of the invention. Moreover, aspreviously described, if claims submitted to server system 14 of FIG. 1exhibit indicia of fraud or mistake, or exceed a threshold dollaramount, the claims can be subjected to additional adjudicationprocedures. In one embodiment, the additional adjudication procedurescan include adjudication techniques described in U.S. patent applicationSer. No. 09/118,668.

The invention can be practiced with additional steps for processing orpaying insurance claims or for communicating the status of submittedclaims to health care providers and patients. For instance, when a claimhas been submitted and approved, an explanation of benefits can beautomatically created and sent to the provider, the patient, and/or toan employer of the patient. Electronic funds transfer can be used toexecute payment from insurers to health care providers for approvedclaims.

FIG. 4A illustrates one embodiment of the methods of the invention forinteractively determining whether a particular patient is a beneficiaryof an approved insurance plan. In step 80, communication is establishedbetween the client system and the server system as described herein. Instep 82, the client system receives and displays the claim form toenable the medical technician to enter the information required tocomplete the insurance claim. As previously noted, the client system canretrieve the claim form from the remote server system or from a localdata storage device. In step 84, the medical technician enters thepatient identification information and transmits the information to theserver system.

In decision block 86, if the server system discovers that the patient isnot a beneficiary of an approved insurance plan, the server systemnotifies the client of this result as shown in step 88. Likewise, if theserver system determines that the patient is a beneficiary, this resultis transmitted to the client system as shown in step 90.

FIG. 4B illustrates one embodiment of the methods of the invention forcreating and submitting insurance claims and determining whether thesubmitted claim is in condition for payment. In step 92, after havingbeen notified that the patient is a beneficiary of an approved insuranceplan, the medical technician enters the diagnosis and treatment codes tothe claim form and transmits these codes to the server system. As shownin decision block 94, the server system performs any desired claimchecking or adjudication process to determine whether the claimdescribes health care services that are approved for payment. If theclaim is not in condition to be paid, the method advances to step 96, inwhich the client system is notified of this result. As shown by decisionblock 98, if the medical technician or the health care provider decidesto revise the claim, the method again advances to step 92.

Referring again to decision block 94, if the server system determinesthat the claim is in condition for payment, the method advances to step100, in which the server system determines the amount to be paid by theinsurer and any co-payment to be collected from the patient. Next, instep 102, the client system displays the payment amount and theco-payment amount to the medical technician or the health care provider.In step 104, any co-payment can then be collected from the patient. Itwill also be appreciated that, in other embodiments, the invention canbe practiced without calculating the co-payment.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrativeand not restrictive. The scope of the invention is, therefore, indicatedby the appended claims rather than by the foregoing description. Allchanges which come within the meaning and range of equivalency of theclaims are to be embraced within their scope.

What is claimed and desired to be secured by United States LettersPatent is:
 1. In a system comprising a client computer and a remoteserver computer connected to the client computer by a communicationlink, a method of interactively preparing an insurance claim inpreparation for a health care provider to perform health care services,the method comprising the steps of: entering, by a health care provider,a diagnosis code and a treatment code to a computer-displayable claimform displayed by the client computer; transmitting the diagnosis codeand the treatment code from the client computer to the remote servercomputer prior to the health care provider performing health careservices; determining, at a processor associated with the remote servercomputer, that the diagnosis code and the treatment code do notcorrespond to health care services that are approved for payment;transmitting information from the remote server computer to the clientcomputer, the information indicating to the health care provider thatthe diagnosis code and the treatment code do not correspond to healthcare services that are approved for payment prior to the health careprovider performing the health care services; and transmitting, from theremote server computer to the client computer, a suggested revisedtreatment code prior to the health care provider performing the healthcare services, such that the treatment associated with the revisedtreatment code can be included in the health care services when thehealth care services are performed by the health care provider.
 2. Amethod as defined in claim 1, wherein the computer-displayable form is ahypertext markup language document.
 3. A method as defined in claim 1,wherein the step of transmitting the diagnosis code and the treatmentcode and the step of transmitting information are both conducted withina single period of time that is short enough so that the health careprovider continues to view the computer-displayable form during thesingle period of time.
 4. A method as defined in claim 1, wherein thestep of transmitting the diagnosis code and the treatment code and thestep of transmitting information are both conducted within a singleperiod of time that is short enough so that the communication betweenthe remote server computer and the client computer is not discontinuedduring the single period of time.
 5. A method as defined in claim 1,wherein the diagnosis code and the treatment code are associated with afirst patient, the method further comprising the steps of: entering, bya health care provider, a second diagnosis code and a second treatmentcode to the claim form; transmitting the second diagnosis code and thesecond treatment code from the client computer to the remote servercomputer; determining, at the processor, whether the second diagnosiscode and the second treatment code correspond to health care servicesthat are approved for payment; and transmitting further information fromthe remote server computer to the client computer, the furtherinformation indicating to the health care provider whether the seconddiagnosis code and the second treatment code correspond to health careservices that are approved for payment.
 6. A method as defined in claim1, further comprising the step of transmitting, from the remote servercomputer to the client computer, data representing an amount to be paidby an insurer to a health care provider who is to perform the healthcare services.
 7. A method as defined in claim 6, further comprising thestep of displaying, by the client computer, co-payment informationrepresenting a co-payment to be collected from a patient who hasreceived the health care services.
 8. A method as defined in claim 7,further comprising the step of collecting the co-payment from thepatient based on the co-payment information.
 9. A method as defined inclaim 8, wherein the step of collecting the co-payment from the patientis conducted during a visit of the patient to an office of the healthcare provider, wherein the patient receives said health care servicesduring said visit.
 10. In a system that includes a remote servercomputer and a client computer capable of communicating with the remoteserver computer, a method of interactively preparing an insurance claimcomprising the steps of: generating a computer-displayable claim formfor display to a health care provider; receiving a diagnosis code and atreatment code entered to the claim form by the health care provider;initiating transmission of the diagnosis code and the treatment codefrom the client computer to the remote server computer prior to thehealth care provider performing health care services associated with thetreatment code; receiving information from the remote server computerindicating to the health care provider that the diagnosis code andtreatment code do not correspond to health care services that areapproved for payment prior to the health care provider performing thehealth care services associated with the treatment code; and receiving,from the remote server computer, a suggested revised treatment codeprior to the health care provider performing the health care services,such that the treatment associated with the revised treatment code canbe included in the health care services when the health care servicesare performed by the health care provider.
 11. A method as defined inclaim 10, wherein the step of transmitting the diagnosis code and thetreatment code and the step of transmitting information are bothconducted within a single period of time that is short enough so thatthe communication between the remote server computer and the clientcomputer is not discontinued during the single period of time.
 12. Amethod as defined in claim 10, further comprising, before the step ofreceiving the diagnosis code and the treatment code, the step oftransmitting patient identification information from the client computerto the remote server computer.
 13. A method as defined in claim 12,further comprising, after the step of transmitting patientidentification information and prior to the health care providerperforming the health care services, the step of receiving verificationfrom the remote server computer that a patient identified by the patientidentification information is a beneficiary of a health insurance plan.14. In a system that includes a client computer and a server systemcapable of communicating with the client computer, a method of informinga health care provider using the client computer whether an insuranceclaim represents health care services that are approved for paymentprior to the health care provider performing the health care services,comprising the steps of: receiving a treatment code and a diagnosis codefrom the client computer, the treatment code and diagnosis code havingbeen entered to the client computer by a health care provider prior tothe health care provider performing health care services; examining thetreatment code and the diagnosis code and determining that the treatmentcode and the diagnosis code do not correspond to health care servicesthat are approved for payment; initiating transmission of information tothe client computer indicating to the health care provider indicatingthat the treatment code and the diagnosis code do not correspond tohealth care services that are approved for payment prior to the healthcare provider performing the health care services, such that the healthcare provider can base a decision regarding whether to perform thehealth care services on whether the health care services are approvedfor payment; and initiating transmission of a suggested revisedtreatment code to the client computer prior to the health care providerperforming the health care services, such that the treatment associatedwith the revised treatment code can be included in the health careservices when the health care services are performed by the health careprovider.
 15. A method as defined in claim 14, further comprising, priorto the step of receiving the treatment code and the diagnosis code,transmitting a computer-displayable claim form to the client computerfor display to the health care provider, the claim form including fieldsfor accepting the treatment code and the diagnosis code.
 16. A method asdefined in claim 15, wherein the step of transmitting acomputer-displayable claim form comprises the step of transmitting ahypertext markup language document from to the client computer via theInternet.
 17. A method as defined in claim 14, wherein the step ofreceiving the diagnosis code and the treatment code and the step oftransmitting information are both conducted within a single period oftime that is short enough so that communication between the remoteserver computer and the client computer is not discontinued during thesingle period of time.
 18. A method as defined in claim 14, wherein thestep of examining the treatment code and the diagnosis code comprisesthe step of comparing the treatment code and the diagnosis code to adatabase having entries that represent currently accepted medicalpractice.
 19. A method as defined in claim 14, wherein the step ofexamining the treatment code and the diagnosis code comprises the stepof determining whether a plurality of treatment codes is consistent withan unbundling claiming practice.
 20. A computer program product forimplementing a method of interactively preparing an insurance claimprior to a health care provider performing health care services that arethe subject of the insurance claim, wherein the method is capable ofbeing performed on a client computer that communicates with a remoteserver computer, the computer program product comprising: acomputer-readable medium carrying computer-executable instructions forimplementing the method, the computer-executable instructionscomprising: program code means for displaying a computer-displayableclaim form to a health care provider; program code means for initiatingtransmission of a diagnosis code and a treatment code from the clientcomputer to the remote server computer prior to the health care providerperforming the health care services; program code means for receiving,from the remote server computer and prior to the health care providerperforming the health care services, information indicating that thediagnosis code and the treatment code do not correspond to health careservices that are approved for payment; and program code means forreceiving, from the remote server computer, a suggested revisedtreatment code prior to the health care provider performing the healthcare services, such that the treatment associated with the revisedtreatment code can be included in the health care services when thehealth care services are performed by the health care provider.
 21. Acomputer program product as defined in claim 20, wherein the programcode means for initiating transmission of the diagnosis code and thetreatment code comprise program code means for communicating with theremote server via the Internet.
 22. A computer program product asdefined in claim 21, wherein the program code means for communicatingwith the remote server via the Internet operate so as to maintaincommunication with the remote server during a time period between thetransmission of the diagnosis code and the treatment code and thereceipt of the information from the remote server computer.
 23. Acomputer program product for implementing, in a server system thatcommunicates with a client system, a method of informing a health careprovider who uses the client computer whether an insurance claimrepresents health care services approved for payment prior to the healthcare provider performing the health care services, the computer programproduct comprising: a computer-readable medium carryingcomputer-executable instructions for implementing the method, thecomputer-executable instructions comprising: program code means forreceiving a treatment code and a diagnosis code from the clientcomputer, the treatment code and diagnosis code having been entered tothe client computer by a health care provider prior to the health careprovider performing health care services; program code means fordetermining whether the treatment code and the diagnosis code correspondto health care services that are approved for payment; and program codemeans for initiating transmission of information to the client computerindicating to the health care provider that the treatment code and thediagnosis code do not correspond to health care services that areapproved for payment prior to the health care provider performing thehealth care services, such that the health care provider can base adecision regarding whether to perform the health care services onwhether the health care services are approved for payment; and programcode means for initiating transmission of a suggested revised treatmentcode, to the client computer, prior to the health care providerperforming the health care services, such that the treatment associatedwith the revised treatment code can be included in the health careservices when the health care services are performed by the health careprovider.
 24. A computer program product as defined in claim 23, whereinthe computer-executable instructions further comprise program code meansfor initiating transmission of a computer-displayable claim form to theclient computer, the claim form including fields for accepting thetreatment code and the diagnosis code.
 25. A computer program product asdefined in claim 23, wherein the computer-executable instructionsfurther comprise: program code means for receiving patientidentification information from the client computer, the patientidentification information identifying an patient of the health careprovider; program code means for determining whether the patient is abeneficiary of a health insurance plan; and program code means forinitiating transmission of data to the client computer indicatingwhether the patient is a beneficiary of a health insurance plan prior tothe health care provider performing the health care services for thepatient.
 26. A computer program product as defined in claim 25, whereinthe program code means for receiving patient identification informationand the program code means for initiating transmission of data operateby communicating with the client computer via the Internet.
 27. Acomputer program product as defined in claim 26, wherein thecomputer-executable instructions further comprise program code means formaintaining communication with the client computer during a time periodbetween the receipt of the diagnosis code and the treatment code and thetransmission of the information to the client computer.